- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $885.46 / $885.46 / $6,907.00
| Facility | | $885.46 | $885.46 | $6,907.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.34 / $344.54 / $1,109.50
| Professional | | $247.34 | $344.54 | $1,109.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,533.78 / $1,533.78 / $2,151.00
| Facility | | $1,533.78 | $1,533.78 | $2,151.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.13 / $306.73 / $513.25
| Professional | | $189.13 | $306.73 | $513.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,027.00 / $1,485.00
| Facility | | $1,000.00 | $1,027.00 | $1,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.06 / $305.98 / $763.30
| Professional | | $229.06 | $305.98 | $763.30 |